Provider Demographics
NPI:1619036589
Name:PROVIDENCE EYE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PROVIDENCE EYE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CESARO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:401-351-5664
Mailing Address - Street 1:50 MAUDE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4325
Mailing Address - Country:US
Mailing Address - Phone:401-351-5664
Mailing Address - Fax:401-456-5726
Practice Address - Street 1:50 MAUDE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4325
Practice Address - Country:US
Practice Address - Phone:401-351-5664
Practice Address - Fax:401-456-5726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9007882Medicaid
RI9007882Medicaid